Acute aluminum encephalopathy in a dialysis center caused by a cement mortar water distribution pipe

In Curaçao, distilled seawater from the water plant was used without further purification for hemodialysis for several decades. A new distribution pipe supplying water to a dialysis center on the island was installed in May 1996. To protect it from corrosion, this pipe was lined on the inside with a cement mortar. Because of the aggressiveness of the distilled water, calcium and aluminum (Al) leached from the cement mortar into the water used to prepare dialysate. This caused a possible hard water syndrome and definite acute Al intoxication.

We reviewed clinical details and outcome at follow-up, and arranged laboratory and toxicological studies of serum and hemodialysis water.

Of the 27 patients who had a similar exposure ( approximately 60 hours) to the contaminated dialysate, 10 died from acute Al encephalopathy, whereas 17 patients had no or only minor symptoms and survived. The nonsurvivors were older (64 +/- 3 years vs. 52 +/- 2 years, P < 0.01) and had a lower body weight (57.5 +/- 5.9 kg vs. 86.5 +/- 4.1 kg, P < 0.01) and lower serum albumin concentrations (33 +/- 1 vs. 36 +/- 1 g/L, P < 0.01). Anuria tended to be more common in the nonsurvivors (8 out of 10 vs. 8 out of 17, P> 0.05). Serum Al concentrations, available in seven nonsurvivors, were significantly higher than in the survivors (808 +/- 127 vs. 255 +/- 25 microg/L, P < 0.01).

The water distribution pipe was lined with a cement mortar that was probably inappropriate for transporting drinking water. Water distribution facilities as well as the dialysis community should be aware of the possibility of Al leaching from cemented water distribution pipes. Similar Al loads appear to induce a more severe intoxication in malnourished, older patients with smaller Al distribution volumes and anuria.